EMM systems can be used to improve incident reporting

The use of electronic medication management and clinical information systems can be used to improve the rate and quality of medication error reporting in Australian hospitals, new research suggests.

In a study published in the International Journal for Quality in Health Care, researchers led by Johanna Westbrook and colleagues from the Centre for Health Systems and Safety Research at Macquarie University in Sydney found that the rate of reporting of medication prescribing and administration errors by clinicians was very low, despite the practice being encouraged and valued for quality improvement and patient safety purposes.

The study examined data from electronic incident reporting systems used at two Sydney hospitals – Riskman and the NSW Health Incident Information Management System – to identify the extent to which medication errors identified following an audit of records and physical observation were reported to the incident reporting systems.

They also wanted to use the data to identify the differences between the two hospitals in their frequency of incident reporting, and to test the hypothesis that low rates of prescribing error detection by staff may be a contributing factor to low medication incident reporting rates.

What they found was that reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates.

“This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals,” they say. “New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.”

The researchers gathered data from clinical audits of 3291 patient records conducted by independent pharmacists on prescribing errors occurring on six medical and surgical wards. Any evidence that medication errors had been detected by staff, such as a correction or note made by a doctor, nurse or pharmacist, was recorded. Prescribing errors were then classified as procedural or clinical.

The study also looked at data on medication administration errors in six wards at the same two hospitals. This data was gathered from direct observations of 180 nurses as they prepared and administered 7451 medications to 1397 patients. These were also classified as procedural or clinical.

The observational data was then compared with patients' medication charts to identify clinical administration errors, with the potential severity for all medication errors rated as insignificant, minor, moderate, major or serious.

Incident data were then extracted from the hospitals' incident reporting systems relating to all prescribing and medication administration errors, with incident reporting rates calculated using the number of errors reported over total errors observed at audit.

The data showed that of 12,567 prescribing errors identified – the majority of which were procedural errors but 539 of which were rated as clinically important errors – about 10 per cent had been detected by hospital staff or patients but only 15 were reported to the hospitals' incident systems.

In terms of medication administration errors, the study identified 10,955, of which 10 per cent were rated as clinically important. None of these errors had an incident report, although during the period 173 errors that were not observed by the research staff were reported to the hospitals incident systems.

The study found that only 1.3 per cent of clinically important prescribing errors, with the potential to cause patient harm, were reported to the hospital incident systems, and for only 10 per cent of these errors was there any evidence that staff had detected the error.

The study cites previously published research investigating the various barriers to reporting incidents, such as lack of time, concerns about repercussions or disciplinary actions and an absence of evidence that the data are used for good purpose. These barriers still seem to remain despite survey evidence which indicates that many Australian nurses and doctors indicate they always report drug errors.

One of the problems that this raises with incident data is the potential to lead decision-makers astray and misdirect resources to solve problems that are easily identifiable.

“Removing barriers to reporting will improve incident data, but a major problem also lies in the very low rate at which prescribing errors are detected by staff,” they write.

“Our results clearly indicate that the incident data hospitals generate have significant limitations in reflecting both the frequency and nature of medication errors occurring.

“Hospital committees and management boards charged with the responsibility for monitoring medication incident reports require clear guidance regarding the strengths and limitations of these data, including guidance on how to interpret changes in the frequency of incident data.”

There are a number of potential solutions to the problem, including encouraging clinicians to view incident reporting as an indicator of an open and safe reporting culture and to see that the value of incidents lie in their ability to identify hazards on which to focus quality improvement activities, they suggest.

Healthcare organisations can also use the emergence of electronic clinical information systems as a way to obtain more reliable and comprehensive medication incident data.

“Electronic prescribing and medication administration record systems capture details of all drugs prescribed and administered,” they write. “They are highly effective at reducing prescribing errors, particularly with well-designed decision support, and when linked with bar-coding of medications they are also effective at reducing administration errors.

“The potential of these technologies to deliver up-to-date data about the quality and safety of medication practices has been under-explored. Automatically mining data derived from these electronic systems, can provide information about both medication errors and near-miss situations.

“These systems will not provide the detailed contextual information available from well-documented incident reports, but they provide a valuable new source of data that should be exploited.”

They conclude that an important implication of their findings is the need for staff responsible for monitoring medication safety to use multiple data sources and more sophisticated approaches, which they suggest are now readily available with electronic medication management systems.

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. DOI: http://dx.doi.org/10.1093/intqhc/mzu098

Comments

I believe this is a very important conclusion from this study and supports the studies by Bates from the Brigham and Women Hospital in Boston and Classen from Intermountain Health Care in Utah.[1-3] “This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals,” they say. “New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.”There is also the close association of ADE prevention and detection associated with the level of medical indemnity claims. Rothschild demonstrated that 73% of the ADE associated with indemnity claims were preventable and the distribution was equal across all parts of the health system.1. Bates, D.W., et al., Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc, 1994. 1(5): p. 404-11.2. Rothschild, J.M., et al., Analysis of medication-related malpractice claims: causes, preventability, and costs. Arch Intern Med, 2002. 162(21): p. 2414-20.3. Classen, D.C., et al., Computerized surveillance of adverse drug events in hospital patients. JAMA, 1991. 266(20): p. 2847-51.